Incident Report - First Response

• Document No.

• Audit Title

• Client / Site / Project

• Report conducted on

  Date

• Prepared by

• Location
  Address

• Foreman

First Incident Details

• Date & Time of Incident

  Date

• Date & Time Safety Department notified

  Date
• Location of Incident
  Address

• Incident Priority?

  Urgent

  High

  Medium

  Low

  Trivial

• Project Name & Number

• Incident Type?

  Select Near Miss Equipment Accident Vehicle Accident Property Damage Utility Damage Incident - Other Theft Vandalism Fire Spills Injury - OSHA Recordable Injury - Report Only Injury - First Aid Illness

  • Near Miss
  • Equipment Accident
  • Vehicle Accident
  • Property Damage
  • Utility Damage
  • Incident - Other
  • Theft
  • Vandalism
  • Fire
  • Spills
  • Injury - OSHA Recordable
  • Injury - Report Only
  • Injury - First Aid
  • Illness

• Name of on-duty supervisor at time of incident?

• Is immediate medical attention required?

  Yes

  No

• What kind of medical attention was administered?

  Select First Aid Designated Medical Facility Hospital Ambulance Medical Attention Declined

  • First Aid
  • Designated Medical Facility
  • Hospital
  • Ambulance
  • Medical Attention Declined

Describe What Happened

• Describe what happened. Please be detailed but state only facts.

• What were the weather / environmental conditions at the time of the incident?

  Select Clear Cloudy Rain Snow Windy Hot Cold Haze Other

  • Clear
  • Cloudy
  • Rain
  • Snow
  • Windy
  • Hot
  • Cold
  • Haze
  • Other

• Describe the weather / environmental conditions at the time of the incident

• Photos (If applicable)

  Media

Record Evidence and Information

• Which of the following do you need to attach to this report to accuractly document this incident?

  Select Evidence Equipment Details Vehicle Details Damages Other Items

  • Evidence
  • Equipment Details
  • Vehicle Details
  • Damages
  • Other Items

Evidence Log

• Please log all relevant evidence below

Evidence

• Evidence Description

• Evidence ID number (if applicable)

• Type of evidence

  Document

  Photos

  Other

• Photos of evidence (if applicable)

  Media

• Please detail any further information regarding this evidence (if applicable)

Vehicle Log

• Please log all relevant vehicle details below

Vehicle

• Vehicle Make

• Vehicle Model

• Vehicle Registration

• Driver (if applicable)

• Photos of equipment (if applicable)

  Media

• Please detail any further information regarding this vehicle (if applicable)

Damage Log

• Please log all relevant damage details below

Damage

• Damage description

• ID number (if applicable)

• Photos of damage (if applicable)

  Media

• Please detail any further information regarding this damage (if applicable)

Other Items Log

• Please log all relevant details of other items below

Item

• Item description

• ID number (if applicable)

• Photos of item (if applicable)

  Media

• Please detail any further information regarding this item (if applicable)

Equipment Log

• Please log all relevant equipment details below

Equipment

• Equipment Make

• Equipment Model

• Equipment ID number (if applicable)

• Photos of equipment (if applicable)

  Media

• Please detail any further information regarding this equipment (if applicable)

People involved

• Please document all people involved in this incident, including yourself (the person reporting the incident)

Person

Person

• Full Name

• Employee Number

• Length of Employment

• What is this person's relation to the incident? (select all that apply)

  Select Reporter of incident Injured person Witness Primary person involved Secondary Involvement On-duty supervisor Investigator Suspect Other

  • Reporter of incident
  • Injured person
  • Witness
  • Primary person involved
  • Secondary Involvement
  • On-duty supervisor
  • Investigator
  • Suspect
  • Other

• Describe this person's relation to the incident

• Please describe this person's involvement with the incident, including all relevant information

• Does this person wish to make a preliminary statement?

  Yes

  No

  N/A

Preliminary Statement

• Statement regarding incident

• Person Signature

  Sign

• Has this person sustained an injury?

  Yes

  No

Injury Details

• Type of injury or illness? (select all that apply)

  Select Laceration Puncture wound Fatality Concussion Sprain Respiratory Eye Injury Burns Fracture Electrocution Fall Strain Dislocation Struck by object Entanglement Assault Muscle & Tendon Nerve & spinal cord Amputation Intracranial Other Injury

  • Laceration
  • Puncture wound
  • Fatality
  • Concussion
  • Sprain
  • Respiratory
  • Eye Injury
  • Burns
  • Fracture
  • Electrocution
  • Fall
  • Strain
  • Dislocation
  • Struck by object
  • Entanglement
  • Assault
  • Muscle & Tendon
  • Nerve & spinal cord
  • Amputation
  • Intracranial
  • Other Injury

• Describe type of injury or illness

• Parts of body affected? (select all that apply)

  Select General Ailment Head Ear (Right) Ear (Left) Eye (Right) Eye (Left) Nose Throat Neck Back (Upper) Back (Lower) Arm - Upper (Right) Arm - Upper (Left) Arm - Elbow (Right) Arm - Elbow (Left) Arm - Forearm (Right) Arm - Forearm (Left) Wrist (Right) Wrist (Left) Hand (Right) Hand (Left) Thumb (Right) Thumb (Left) Chest Abdominal / Stomach Groin / Anus Leg - Upper (Right) Leg - Upper (Left) Leg - Knee (Right) Leg - Knee (Left) Leg - Lower (Right) Leg - Lower (Left) Ankle (Right) Ankle (Left) Foot (Right) Foot (Left) Shoulder (Left) Shoulder (Right) Other

  • General Ailment
  • Head
  • Ear (Right)
  • Ear (Left)
  • Eye (Right)
  • Eye (Left)
  • Nose
  • Throat
  • Neck
  • Back (Upper)
  • Back (Lower)
  • Arm - Upper (Right)
  • Arm - Upper (Left)
  • Arm - Elbow (Right)
  • Arm - Elbow (Left)
  • Arm - Forearm (Right)
  • Arm - Forearm (Left)
  • Wrist (Right)
  • Wrist (Left)
  • Hand (Right)
  • Hand (Left)
  • Thumb (Right)
  • Thumb (Left)
  • Chest
  • Abdominal / Stomach
  • Groin / Anus
  • Leg - Upper (Right)
  • Leg - Upper (Left)
  • Leg - Knee (Right)
  • Leg - Knee (Left)
  • Leg - Lower (Right)
  • Leg - Lower (Left)
  • Ankle (Right)
  • Ankle (Left)
  • Foot (Right)
  • Foot (Left)
  • Shoulder (Left)
  • Shoulder (Right)
  • Other

• Please describe injury location

• Describe this injury or illness

• Type of work employee was doing at time of injury

  Select Grading Excavation Paving (asphalt or concrete) Concrete (structural) Concrete (non-structural) Maintenance Bridge work Box structure Form and pour Silo work Material handling Utility installation (water, sewer, storm, etc.) Office Driving

  • Grading
  • Excavation
  • Paving (asphalt or concrete)
  • Concrete (structural)
  • Concrete (non-structural)
  • Maintenance
  • Bridge work
  • Box structure
  • Form and pour
  • Silo work
  • Material handling
  • Utility installation (water, sewer, storm, etc.)
  • Office
  • Driving

• What was the cause of this injury or illness?

Root Cause Analysis

• Was a JHA completed by the supervisor and is it documented?

  Yes

  No

  N/A

• Was this incident discussed in the JHA?

  Yes

  No

  N/A

• Was Stretch Flex exercises performed today?

  Yes

  No

  N/A

• Who trained the employee of the hazards and protective measures for the task?

• What training was given to employee?

• What safety rules were in place to prevent this type of incident?

• Was the proper PPE being used for the task?

• Was the supervisor onsite when the incident occurred?

  Yes

  No

  N/A

• When had the supervisor last checked on progress?

• Where was the supervisor at the time of the incident?

• Unsafe Acts:

  Select Failure to lockout/Tagout Using defective equipment Improper work technique Improper PPE - not used or used correctly Safety rule violation Operating without qualification or authorization Failure to warn or secure Operating equipment at an unsafe speed Bypass or removal of safety devices Taking an unsafe position or posture Improper loading or placement Improper lifting Use of tools for other than their intended purpose Servicing or adjusting machinery in motion Horseplay Drug or Alcohol use Unsafe act(s) of others Failure to secure or tie down materials to prevent unexpected movement

  • Failure to lockout/Tagout
  • Using defective equipment
  • Improper work technique
  • Improper PPE - not used or used correctly
  • Safety rule violation
  • Operating without qualification or authorization
  • Failure to warn or secure
  • Operating equipment at an unsafe speed
  • Bypass or removal of safety devices
  • Taking an unsafe position or posture
  • Improper loading or placement
  • Improper lifting
  • Use of tools for other than their intended purpose
  • Servicing or adjusting machinery in motion
  • Horseplay
  • Drug or Alcohol use
  • Unsafe act(s) of others
  • Failure to secure or tie down materials to prevent unexpected movement

• Unsafe Acts (Other):

• Unsafe Conditions:

  Select Defective tools, equipment or supplies Inadequate supports or guards Congested work area Lack of adequate guards Lack of adequate warning system Fire or explosion hazard Poor housekeeping Poor work station design or layout Hazardous atmosphere Inadequate ventilation Excessive noise Hazardous substances Improper material storage Insufficient job knowledge Slippery conditions Insufficient lighting Inadequate fall protection Impalement hazards

  • Defective tools, equipment or supplies
  • Inadequate supports or guards
  • Congested work area
  • Lack of adequate guards
  • Lack of adequate warning system
  • Fire or explosion hazard
  • Poor housekeeping
  • Poor work station design or layout
  • Hazardous atmosphere
  • Inadequate ventilation
  • Excessive noise
  • Hazardous substances
  • Improper material storage
  • Insufficient job knowledge
  • Slippery conditions
  • Insufficient lighting
  • Inadequate fall protection
  • Impalement hazards

• Unsafe Conditions (Other):

• Management System Deficiencies:

  Select Lack of written procedures or safety rules Safety rules not enforced Hazards not identified PPE unavailable Insufficient worker training Insufficient supervisor training Improper maintenance Inadequate supervision Insufficient job planning Failure to pre-task Inadequate workplace inspections Unsafe design or construction Unrealistic scheduling

  • Lack of written procedures or safety rules
  • Safety rules not enforced
  • Hazards not identified
  • PPE unavailable
  • Insufficient worker training
  • Insufficient supervisor training
  • Improper maintenance
  • Inadequate supervision
  • Insufficient job planning
  • Failure to pre-task
  • Inadequate workplace inspections
  • Unsafe design or construction
  • Unrealistic scheduling

• Management System Deficiencies (Other):

Corrective Actions

• Are corrective/further actions required with regard to this incident?

  Yes

  No

• List action(s) that have or will be taken to prevent a recurrence

• Have all required corrective actions been added as Actions to this inspection?

  Yes

  No

  N/A

Reported By:

• Further action/follow-up/investigation required?

  Yes

  No

• Name of person/people to follow up

• Name

  Select